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Bladder stones
BLADDER STONES * AN EXTRAVESICAL JOSEPH
E.
MAURER,
M.D.,
ROBERT
SURGICAL
LICH,
JR.,
M.D.
APPROACH AND
STEPHEN
B.
BURDON,
M.D.
Louisville, Kentucky ESICOLITHOTOMY as practiced by the use of a high cystotomy is not aIways foIIowed with a postoperative course comparabIe to the patient’s initia1 anticipated risk. It has Iong been recognized that this operation carried with it an unpredictabIe morbidity and mortaIity. It is for this reason that we considered the advisabiIity of another approach and chose the prostatic capsuIar incision because of the appreciabIy better bIood suppIy ofthis structure. Our method and experience are reported herein aIong with ten iIIustrative cases. Anatomic Considerations. Wound heaIing is dependent upon a muItitude of factors, the most important of which is the avaiIabIe blood suppIy. This we beIieve may account for the deIay in heaIing of cystotomy wounds executed for vesicoIithotomy. It is common to see these bIadder wounds hea poorIy, and this finding is in contradistinction to the cystotomy wound that is performed for vesica1 drainage aIone. It wouId seem that the presence of the caIcuIus must initiate some change which might secondariIy affect the vascuIarity of the bIadder fundus. CIinicaIIy, it is appreciated that the vesical fundus seIdom affords sufficient bIeeding to be troubIesome upon incision. The presence of a caIcuIus in the bIadder may aIter the bIood suppIy to a further degree and so reduce its effectiveness. In any event, in an attempt to soIve this perpIexing probIem it occurred to us that if funda avascuIarity was a factor, incision through the prostatic capsuIe shouId certainIy circumvent this possibiIity. In the execution of retropubic prostatectomy we found the prostate and vesica1 neck to be characterized by extreme vascuIarity but stiII quite amenable to satisfactory hemostasis. With these concepts in mind it was decided to initiate a series of vesicoIithotomies through the prostatic urethra. The arteria1 bIood suppIy of the urinary bIadder is derived from severa rather variabIe arteries a11 of which take origin from the hypo-
V
* From the Section on UroIogy, Department
March,
1931
gastric arteries. Farabeuf and Tsaknis have studied the vesical bIood suppIy rather thoroughIy and through their efforts one can generalize to a certain extent regarding this phase of vesical anatomy. The anterosuperior and posterosuperior vesica1 arteries are derived from a common trunk
IA
IB
FIG. I. A, anterior view of the veins of the bladder; (I) Santorini’s pIexus; (2) Iateral veins of bIadder; (3) inferior vesicaI veins. B, anterior view of the arteries of the bladder; (I) epigastric artery; (2) umbilical artery; (3) ascending anterior vesical artery; (4) obturator artery; (5) prostatic artery; (6) vesical branch of genitovesical artery; (7) genitovesica1 artery; (8) anterosuperior vesica1 artery; (9) posterosuperior vesica1 artery; (IO) superior vesical trunk; (I I) hypogastric artery (after Tsaknis).
with the umbiIica1 arteries. (Fig. I.) These vesseIs suppIy the dome of the bladder. The genitovesica1 and prostatic arteries frequentIy derive from a common trunk, and after dividing into these respective branches, form the rich bIood suppIy to the prostate, semina1 vesicIes and the bIadder neck. The Iatter structure is
of Surgery, University of LouisviIIe School of Pledicine, Louisville, Ky.
295
Maurer
et al.-Bladder
supphed by the inferior vesicaI arteries. Thus the arteriat bIood suppIy to the vesical neck region is greater than that to the fundus, in proportion to the amount of tissue suppIied. The veins are not concomitant with the arteries but form a rich pIexus on the anteroinferior aspect of the bIadder. Here they merge with the veins of the prostatic plexus which Iie within and upon the anterior surface of the prostatic sheath. The uItimate drainage is into the IateraI vesica1 pIexus and from there into the hypogastric veins. Therefore, it is readiIy apparent that the arteria1 and venous suppIy to the vesica1 neck region greatIy exceeds that of the fundus. Two of the primary requisites of tissue heaIing are immobiIization of the wound and an adequate bIood suppIy. The incision into the anterior aspect of the vesica1 fundus fuIfiIIs neither of these criteria, for even though drainage is instituted by means of a suprapubic tube in an effort to put the bIadder at rest, the not infrequent occurrence of bIadder spasms, coupIed with abdomina1 respiratory movements, cause motion on the suture Iine. In addition, one has to dea1 with a granuating wound once the tube is removed. Clinical Applicability. In ten recent cases we have removed caIcuIi from the bIadder by the method to be described and the unbeIievabIy smooth course, the primary wound heaIing and the freedom from postoperative pain Iead us to beIieve this to be a superior method in those cases in which the stones are no greater than 2 inches in diameter and in which no tumors of the bIadder or remedia1 diverticuIas coexist. We found that it was possibIe by persistent aIthough forcibIe diIatation of the vesica1 neck to expand the opening so that caIcuIi of more than 2 inches in diameter couId be delivered. The vesicaI neck wouId contract immediateIy to its norma caIiber and this process occurs under the observer’s eye prior to reconstruction of the prostatic urethra. The majority of vesica1 caIcuIi seen in our cIinic are secondary to obstructive conditions of the vesica1 neck, i.e., prostatism, vesica1 neck contracture, hypertrophied interureteric ridge and occasionaIIy posterior urethra1 vaIves. The retropubic method aIIows one to correct simuItaneousIy any of these conditions far more satisfactoriIy than is possibIe when the transvesical approach is used. Postoperative urinary drainage is effected by means of a
Stones
urethra1 catheter only, and the wound of the prostatic capsuIe and of the body waI1 is allowed to heal per primam. Surgical Technic. The operative approach is identica1 to that presented by MiIIin for retropubic prostatectomy. This has been presented in detaiI in previous pubIications and wiI1 be reviewed brietIy. A Iow transverse suprapubic skin incision is made and carried down to the rectus sheath. The sheath is divided transverseIy and the rectus mu&es separated in the midline. The bladder, which has previousIy been emptied by catheter, is paIpated and the loose areoIar tissue in the space of Retzius is gentIy swept cephaIad. Three-bIaded retraction is then appIied and the prostatic sheath is inspected. In the case which presents prostatic hypertrophy we prefer the transverse prostatic capsuIar incision, but in chiIdren and in aduIts with other vesica1 pathoIogic disorders we use a vertica1 incision into the prostatic capsuIe. Prior to this incision the appropriate veins in the prostatic sheath are Iigated or sutured so that bIeeding is minima1 at the time of section. The remaining bIeeding points are deaIt with individuaIIy. If the obstruction is due to prostatic enIargement, the gIand is then enucIeated, cut free from the urethra and vesica1 neck and the prostatic arteries Iocated and sutured. SmaIIer bIeeding points in the vesica1 neck are eIectrocoagmated, and digita examination of the bIadder cavity is made. Stone forceps are introduced and the stone is extracted. In no case to date has this maneuver been difhcuIt. If the obstruction is due to hypertrophied interureteric ridge, to median bar or to congenita1 vaIve, appropriate resection and hemostasis is performed, care being taken to remove a11 of the obstructing tissue. This is not diffrcuIt due to the exceIIent exposure obtained. The entire operative area is then inspected and hushed free of detritus and such smaI1 cIots as may have accumuIated. A suitabIe catheter is introduced through the urethra into the bIadder, and the cut edges of the prostatic capsuIe are approximated with a running suture of chromic catgut. The rectus fascia is cIosed with interrupted sutures and the skin is approximated. A rubber tissue drain is Iaid near to but not touching the suture line in the capsuIe. This drain is shortened on the second day and is removed on the third. American
Journal
of Surgery
Maurer et aI.-Bladder TABLE
Stones
297
I
T I
Patient
41Diameter
i (Yr.) Ag’
v. s.
73
.I. P.
66
Contracted vesical neck B. P. H.*
4
B. P. Il.* B. P. II.”
G. E. hl. C.
Remarks
Calculus
stones, 3-4 cm. 2 stones, 1.5 cm. 2 cm. 3 stones, 5
Stones were located in huge diverticulum vesical neck True lateral lobe enlargement
near
2 cm.
C. B. J. B. M. R. J. F.
76 76 80
72
w. P.
9
S. A.
53
-I
cm. cm. 5 cm. 2.5 cm.
B. P. H.* B. P. H.* B. P. H.* Fibrosis of prostate CongenitaI fibrotic bar Hypertrophied interureteric ridge
5.5
(uric acid) calculus
0.8 cm.
Stone Iodged in prostatic urethra Stone Iodged in prostatic urethra Non-opaque stone; suprapubic tated reinsertion of catheter
leakage necessi-
4 cm.
-
* Benign prostatic
hypertrophy.
The catheter is Ieft in place for three to four days as a ruIe. The patient is aIlowed out of bed on the first or second postoperative day. RESULTS
AND
CONCLUSIONS
A brief r&sumi: of our patients who underwent retropubic vesicohthotomy is tabuIated. (TabIe I.) The average postoperative hospita1 stay was 10.1 days, the shortest being six days and the longest nineteen days. The postoperative catheter drainage period averaged 5.6 days. AI1 patients enjoyed an extremeIy benign postoperative course and the onIy temporary suprapubic urinary fistuIa occurred in an infant (W. P.). This fistuIa heaIed spontaneousIy after four additional days of urethra1 catheter drainage. The first patient (V. S.) required
March,
Non-opaque
2.5
1951
vesical neck dilatation to aIIow removal of the five large stones. In spite of the fact that this patient retained his Iarge inoperable diverticulum his convalescence was without complication. REFERENCES
FARABEUF, L. H. Les vaisseaux sanguins des organes genitourinaires du perinee et du pelvis. (Amplifrcation de Ia these du Dr. Leon Cerf.) Paris, 1905. Masson et Cie. GRANT, O., LICH, R. JR. and MAURER, J. E. Retropubic prostatectomy. Ural. ef Cutan. Rev., 52: 9, 1948. GRANT, 0. and LICH, R. JR. Rationale and results in retropubic prostatectomy. Ann. Surg., 127: 1010, r948. MILLIN, TERENCE. Retropubic Urinary Surgery, pp. 81-97. Baltimore. The WiIIiams and WiIkins Co. TSAKNI~, DENIS. Les pCdicuIes vascuIaires de Ia vessie et son peritoine chez I’homme. Arch. d. mal. d. reins, 3: 442, 1929.
E.
MAURER,
M.D.,
ROBERT
SURGICAL
LICH,
JR.,
M.D.
APPROACH AND
STEPHEN
B.
BURDON,
M.D.
Louisville, Kentucky ESICOLITHOTOMY as practiced by the use of a high cystotomy is not aIways foIIowed with a postoperative course comparabIe to the patient’s initia1 anticipated risk. It has Iong been recognized that this operation carried with it an unpredictabIe morbidity and mortaIity. It is for this reason that we considered the advisabiIity of another approach and chose the prostatic capsuIar incision because of the appreciabIy better bIood suppIy ofthis structure. Our method and experience are reported herein aIong with ten iIIustrative cases. Anatomic Considerations. Wound heaIing is dependent upon a muItitude of factors, the most important of which is the avaiIabIe blood suppIy. This we beIieve may account for the deIay in heaIing of cystotomy wounds executed for vesicoIithotomy. It is common to see these bIadder wounds hea poorIy, and this finding is in contradistinction to the cystotomy wound that is performed for vesica1 drainage aIone. It wouId seem that the presence of the caIcuIus must initiate some change which might secondariIy affect the vascuIarity of the bIadder fundus. CIinicaIIy, it is appreciated that the vesical fundus seIdom affords sufficient bIeeding to be troubIesome upon incision. The presence of a caIcuIus in the bIadder may aIter the bIood suppIy to a further degree and so reduce its effectiveness. In any event, in an attempt to soIve this perpIexing probIem it occurred to us that if funda avascuIarity was a factor, incision through the prostatic capsuIe shouId certainIy circumvent this possibiIity. In the execution of retropubic prostatectomy we found the prostate and vesica1 neck to be characterized by extreme vascuIarity but stiII quite amenable to satisfactory hemostasis. With these concepts in mind it was decided to initiate a series of vesicoIithotomies through the prostatic urethra. The arteria1 bIood suppIy of the urinary bIadder is derived from severa rather variabIe arteries a11 of which take origin from the hypo-
V
* From the Section on UroIogy, Department
March,
1931
gastric arteries. Farabeuf and Tsaknis have studied the vesical bIood suppIy rather thoroughIy and through their efforts one can generalize to a certain extent regarding this phase of vesical anatomy. The anterosuperior and posterosuperior vesica1 arteries are derived from a common trunk
IA
IB
FIG. I. A, anterior view of the veins of the bladder; (I) Santorini’s pIexus; (2) Iateral veins of bIadder; (3) inferior vesicaI veins. B, anterior view of the arteries of the bladder; (I) epigastric artery; (2) umbilical artery; (3) ascending anterior vesical artery; (4) obturator artery; (5) prostatic artery; (6) vesical branch of genitovesical artery; (7) genitovesica1 artery; (8) anterosuperior vesica1 artery; (9) posterosuperior vesica1 artery; (IO) superior vesical trunk; (I I) hypogastric artery (after Tsaknis).
with the umbiIica1 arteries. (Fig. I.) These vesseIs suppIy the dome of the bladder. The genitovesica1 and prostatic arteries frequentIy derive from a common trunk, and after dividing into these respective branches, form the rich bIood suppIy to the prostate, semina1 vesicIes and the bIadder neck. The Iatter structure is
of Surgery, University of LouisviIIe School of Pledicine, Louisville, Ky.
295
Maurer
et al.-Bladder
supphed by the inferior vesicaI arteries. Thus the arteriat bIood suppIy to the vesical neck region is greater than that to the fundus, in proportion to the amount of tissue suppIied. The veins are not concomitant with the arteries but form a rich pIexus on the anteroinferior aspect of the bIadder. Here they merge with the veins of the prostatic plexus which Iie within and upon the anterior surface of the prostatic sheath. The uItimate drainage is into the IateraI vesica1 pIexus and from there into the hypogastric veins. Therefore, it is readiIy apparent that the arteria1 and venous suppIy to the vesica1 neck region greatIy exceeds that of the fundus. Two of the primary requisites of tissue heaIing are immobiIization of the wound and an adequate bIood suppIy. The incision into the anterior aspect of the vesica1 fundus fuIfiIIs neither of these criteria, for even though drainage is instituted by means of a suprapubic tube in an effort to put the bIadder at rest, the not infrequent occurrence of bIadder spasms, coupIed with abdomina1 respiratory movements, cause motion on the suture Iine. In addition, one has to dea1 with a granuating wound once the tube is removed. Clinical Applicability. In ten recent cases we have removed caIcuIi from the bIadder by the method to be described and the unbeIievabIy smooth course, the primary wound heaIing and the freedom from postoperative pain Iead us to beIieve this to be a superior method in those cases in which the stones are no greater than 2 inches in diameter and in which no tumors of the bIadder or remedia1 diverticuIas coexist. We found that it was possibIe by persistent aIthough forcibIe diIatation of the vesica1 neck to expand the opening so that caIcuIi of more than 2 inches in diameter couId be delivered. The vesicaI neck wouId contract immediateIy to its norma caIiber and this process occurs under the observer’s eye prior to reconstruction of the prostatic urethra. The majority of vesica1 caIcuIi seen in our cIinic are secondary to obstructive conditions of the vesica1 neck, i.e., prostatism, vesica1 neck contracture, hypertrophied interureteric ridge and occasionaIIy posterior urethra1 vaIves. The retropubic method aIIows one to correct simuItaneousIy any of these conditions far more satisfactoriIy than is possibIe when the transvesical approach is used. Postoperative urinary drainage is effected by means of a
Stones
urethra1 catheter only, and the wound of the prostatic capsuIe and of the body waI1 is allowed to heal per primam. Surgical Technic. The operative approach is identica1 to that presented by MiIIin for retropubic prostatectomy. This has been presented in detaiI in previous pubIications and wiI1 be reviewed brietIy. A Iow transverse suprapubic skin incision is made and carried down to the rectus sheath. The sheath is divided transverseIy and the rectus mu&es separated in the midline. The bladder, which has previousIy been emptied by catheter, is paIpated and the loose areoIar tissue in the space of Retzius is gentIy swept cephaIad. Three-bIaded retraction is then appIied and the prostatic sheath is inspected. In the case which presents prostatic hypertrophy we prefer the transverse prostatic capsuIar incision, but in chiIdren and in aduIts with other vesica1 pathoIogic disorders we use a vertica1 incision into the prostatic capsuIe. Prior to this incision the appropriate veins in the prostatic sheath are Iigated or sutured so that bIeeding is minima1 at the time of section. The remaining bIeeding points are deaIt with individuaIIy. If the obstruction is due to prostatic enIargement, the gIand is then enucIeated, cut free from the urethra and vesica1 neck and the prostatic arteries Iocated and sutured. SmaIIer bIeeding points in the vesica1 neck are eIectrocoagmated, and digita examination of the bIadder cavity is made. Stone forceps are introduced and the stone is extracted. In no case to date has this maneuver been difhcuIt. If the obstruction is due to hypertrophied interureteric ridge, to median bar or to congenita1 vaIve, appropriate resection and hemostasis is performed, care being taken to remove a11 of the obstructing tissue. This is not diffrcuIt due to the exceIIent exposure obtained. The entire operative area is then inspected and hushed free of detritus and such smaI1 cIots as may have accumuIated. A suitabIe catheter is introduced through the urethra into the bIadder, and the cut edges of the prostatic capsuIe are approximated with a running suture of chromic catgut. The rectus fascia is cIosed with interrupted sutures and the skin is approximated. A rubber tissue drain is Iaid near to but not touching the suture line in the capsuIe. This drain is shortened on the second day and is removed on the third. American
Journal
of Surgery
Maurer et aI.-Bladder TABLE
Stones
297
I
T I
Patient
41Diameter
i (Yr.) Ag’
v. s.
73
.I. P.
66
Contracted vesical neck B. P. H.*
4
B. P. Il.* B. P. II.”
G. E. hl. C.
Remarks
Calculus
stones, 3-4 cm. 2 stones, 1.5 cm. 2 cm. 3 stones, 5
Stones were located in huge diverticulum vesical neck True lateral lobe enlargement
near
2 cm.
C. B. J. B. M. R. J. F.
76 76 80
72
w. P.
9
S. A.
53
-I
cm. cm. 5 cm. 2.5 cm.
B. P. H.* B. P. H.* B. P. H.* Fibrosis of prostate CongenitaI fibrotic bar Hypertrophied interureteric ridge
5.5
(uric acid) calculus
0.8 cm.
Stone Iodged in prostatic urethra Stone Iodged in prostatic urethra Non-opaque stone; suprapubic tated reinsertion of catheter
leakage necessi-
4 cm.
-
* Benign prostatic
hypertrophy.
The catheter is Ieft in place for three to four days as a ruIe. The patient is aIlowed out of bed on the first or second postoperative day. RESULTS
AND
CONCLUSIONS
A brief r&sumi: of our patients who underwent retropubic vesicohthotomy is tabuIated. (TabIe I.) The average postoperative hospita1 stay was 10.1 days, the shortest being six days and the longest nineteen days. The postoperative catheter drainage period averaged 5.6 days. AI1 patients enjoyed an extremeIy benign postoperative course and the onIy temporary suprapubic urinary fistuIa occurred in an infant (W. P.). This fistuIa heaIed spontaneousIy after four additional days of urethra1 catheter drainage. The first patient (V. S.) required
March,
Non-opaque
2.5
1951
vesical neck dilatation to aIIow removal of the five large stones. In spite of the fact that this patient retained his Iarge inoperable diverticulum his convalescence was without complication. REFERENCES
FARABEUF, L. H. Les vaisseaux sanguins des organes genitourinaires du perinee et du pelvis. (Amplifrcation de Ia these du Dr. Leon Cerf.) Paris, 1905. Masson et Cie. GRANT, O., LICH, R. JR. and MAURER, J. E. Retropubic prostatectomy. Ural. ef Cutan. Rev., 52: 9, 1948. GRANT, 0. and LICH, R. JR. Rationale and results in retropubic prostatectomy. Ann. Surg., 127: 1010, r948. MILLIN, TERENCE. Retropubic Urinary Surgery, pp. 81-97. Baltimore. The WiIIiams and WiIkins Co. TSAKNI~, DENIS. Les pCdicuIes vascuIaires de Ia vessie et son peritoine chez I’homme. Arch. d. mal. d. reins, 3: 442, 1929.